Provider Demographics
NPI:1245585470
Name:MEDINA, JACOB (LPN)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 GELSTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1524
Mailing Address - Country:US
Mailing Address - Phone:716-533-7175
Mailing Address - Fax:
Practice Address - Street 1:85 GELSTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1524
Practice Address - Country:US
Practice Address - Phone:716-533-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244459164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY244459OtherNURSING LICENSE